Catheter insertion system and method of fabrication

ABSTRACT

A robotic instrument driver for elongate members includes a first carriage positionable on a bed and beside a patient access site for manipulating a first elongate member, and a second carriage positionable proximate the bed, the second carriage configured to articulate the first elongate member, wherein the second carriage is movable independent from the first carriage.

BACKGROUND

Robotic interventional systems and devices are well suited forperforming minimally invasive medical procedures as opposed toconventional techniques wherein a patient’s body cavity is open topermit a surgeon’s hands to have access to internal organs. Advances intechnology have led to significant changes in the field of medicalsurgery such that less invasive surgical procedures, in particular,minimally invasive surgery (MIS), are increasingly popular.

MIS is generally defined as surgery performed by entering the bodythrough the skin, a body cavity, or an anatomical opening utilizingsmall incisions rather than large, open incisions in the body. With MIS,it is possible to achieve less operative trauma for the patient, reducedhospitalization time, less pain and scarring, reduced incidence ofcomplications related to surgical trauma, lower costs, and a speedierrecovery.

MIS apparatus and techniques have advanced to the point where anelongated catheter instrument is controllable by selectively operatingtensioning control elements within the catheter instrument. At least twotypes of catheters may be employed for surgical procedures. One typeincludes an electrophysiology (EP) catheter typically uses a navigatingdistance of 15 cm or less. EP catheters also may be relatively thick andstiff and thus, due their short length and high stiffness, EP catheterstypically do not suffer from a tendency to buckle during use.

In comparison to EP procedures, vascular procedures include a greateramount of catheter insertion length, a greater number of catheterarticulation degrees of freedom (DOFs), and a mechanism for manipulationof a guide wire. For that reason, a bedside system provides mounting forsplayer actuation hardware configured to provide the catheter insertionlengths, mounting which accounts for an increase in splayer size due toadded DOFs, and mounting for a guide wire manipulator. Thus, vascularcatheters typically include a relatively long stroke, such as one meteror more. Relative to EP catheters, vascular catheters are typicallysmaller, thinner, and more flexible, and therefore have a greatertendency to buckle than EP catheters. As such, it is typically desirableto feed vascular catheters into the patient with minimal bending toreduce the tendency to buckle. Known vascular robotic catheter systemsare therefore typically suspended over the patient that is lying proneon a bed.

A vascular catheter system typically includes elongate members thatinclude an outer catheter (sheath), an inner catheter (leader), and aguidewire. Each is separately controllable and therefore they cantelescope with respect to one another. For instance, a sheath carriagecontrols operation of the sheath and is moveable in a generally axialmotion along the patient, and a leader carriage controls operation ofthe guidewire and is likewise moveable in the generally axial directionof the patient. Typically, the leader carriage and the sheath carriageare positioned on a remote catheter manipulator (RCM), which issupported by a setup joint (SUJ). The SUJ is typically positioned on arail that is itself mounted to the bed, below which the patient ispositioned.

As such, the RCM typically carries the weight of both carriages as wellas the other hardware that are used to operate the system. And, toprovide the full stroke, the SUJ is passed through the full range ofmotion which, as stated, can exceed one meter. To do so, typically theSUJ is moved or rotated with respect to the rail and the rail isstationary. For this reason, a bedside system is typically included thatprovides mounting for splayer actuation hardware configured to providecatheter insertion lengths, and mounting for a guide wire manipulator.Because this hardware is mounted on the rail, the system can not only becumbersome to work with, but it can interfere with other systemoperation (such as the C-arm and monitors), as well as providesignificant weight that is carried by the bed.

Thus, there is a need to for an improved catheter system that operatesover a smaller footprint, weighs less, and does not compromise thepropensity for the catheter to buckle.

SUMMARY

A robotic instrument driver for elongate members includes a firstcarriage positionable on a bed and beside a patient access site formanipulating a first elongate member, and a second carriage positionableproximate the bed, the second carriage configured to articulate thefirst elongate member, wherein the second carriage is movableindependent from the first carriage.

A catheter surgical system coupled to a bed configured to support apatient during surgery, the system includes a first carriage configuredto couple to the bed and to manipulate a first elongate member, and asecond carriage configured to couple to the bed adjacent to where thepatient is positioned during surgery, wherein the second carriage isconfigured to articulate the first elongate member, and the secondcarriage is moveable autonomously from the first carriage.

A method of assembling a catheter insertion system includes providing afirst carriage that is positionable proximate a patient surgical supportstructure, the first carriage configured to manipulate an elongatemember into a patient, and providing a second carriage that ispositionable proximate the patient surgical support structure and besidea patient on the patient surgical support structure, wherein the secondcarriage is configured to articulate the first elongate member and ismoveable independently from the first carriage.

BRIEF DESCRIPTION OF THE DRAWINGS

While the claims are not limited to a specific illustration, anappreciation of the various aspects is best gained through a discussionof various examples thereof. Referring now to the drawings, exemplaryillustrations are shown in detail. Although the drawings represent theillustrations, the drawings are not necessarily to scale and certainfeatures may be exaggerated to better illustrate and explain aninnovative aspect of an example. Further, the exemplary illustrationsdescribed herein are not intended to be exhaustive or otherwise limitingor restricted to the precise form and configuration shown in thedrawings and disclosed in the following detailed description. Exemplaryillustrations are described in detail by referring to the drawings asfollows:

FIG. 1 is a perspective view of an illustration of a roboticallycontrolled surgical system, according to one exemplary illustration;

FIG. 2 illustrates a plan view of the system of FIG. 1 ; and

FIGS. 3 and 4 illustrate exemplary components of the catheter insertionof FIGS. 1 and 2 .

DETAILED DESCRIPTION

Referring to FIGS. 1 and 2 , a robotically controlled surgical system100 is illustrated in which an apparatus, a system, and/or method may beimplemented according to various exemplary illustrations. System 100includes a robotic instrument driver or catheter insertion system 102having a robotic or first or outer steerable complement, otherwisereferred to as a sheath instrument or sheath carriage 104 and an innersteerable component or otherwise referred to as a leader carriage 106 ona base 108.

During use, a patient is positioned on an operating table or surgicalbed 110 (generally referred to as “operating table”) to which sheathcarriage 104 and leader carriage 106 are coupled or mounted. In theillustrated example, system 100 includes an operator workstation 112, anelectronics rack 114 and an associated bedside electronics box (notshown). Surgical bed 110 is positioned on a base or support 116. Asurgeon is seated at operator workstation 112 and can monitor thesurgical procedure, patient vitals, and control one or more catheterdevices.

System components may be coupled together via a plurality of cables orother suitable connectors 118 to provide for data communication, or oneor more components may be equipped with wireless communicationcomponents to reduce or eliminate cables 118. Communication betweencomponents may also be implemented over a network or over the internet.In this manner, a surgeon or other operator may control a surgicalinstrument while being located away from or remotely from radiationsources, thereby decreasing radiation exposure. Because of the optionfor wireless or networked operation, the surgeon may even be locatedremotely from the patient in a different room or building.

FIG. 2 is a plan view of system 100 of FIG. 1 (with workstation 112 andelectronics rack 114 omitted). As seen in FIGS. 1 and 2 , roboticinstrument driver 102 includes a rail 120 on which sheath carriage 104and leader carriage 106 are positioned and to which they are coupled.Both carriages 104, 106 are positioned proximate bed 110 and in oneembodiment are positioned on rail 120, which itself is positioned on andattached to bed 110. Rail 120, in the illustrated embodiment, ispositioned beside the patient. That is, rail 120 is positioned proximatea location on the bed where the patient lies during a surgicalprocedure.

An elongate member 122 that may include an inner catheter and/orguidewire extends between sheath carriage 104 and leader carriage 106,and generally along a length direction 124 for bed 110. Carriages 104,106 are also each moveable along rail 120 and along direction 124, whichin one embodiment is defined also as an advancement axis for elongateelements of the catheter. According to one embodiment, direction 124also corresponds to a longitudinal axis of bed 120, which generallycorresponds to a length direction of the patient. However, it iscontemplated that carriages 104, 106 may also be positioned with respectto one another and at an angular orientation with respect to thelongitudinal axis of the patient positioned on bed 110. That is, in oneembodiment (not shown) rail 120 is positioned at an angle (other thanzero degrees) with respect to the longitudinal axis of the patient tobetter angle components of the catheter with respect to the patient.Leader carriage 106 is configured to advance or retract elongate member122 when leader carriage 106 is moved along a guidewire axis 126 that isdefined as an axis between sheath carriage 104 and leader carriage 106.Each carriage 104, 106 is positionable proximate bed 110 andpositionable beside a patient on bed 110, and also repositionable duringsurgery. Carriage 104, 106 are each moveable independently orautonomously from one another.

Sheath carriage 104 is rotatable about a sheath carriage rotation axis128. Axis 128 is, in the illustrated embodiment, generally andapproximately orthogonal to guidewire axis 126, and also generallyorthogonal to direction 124. In such fashion, a sheath 130 is extendable(for instance, during surgery) from sheath carriage 104 and is alsodirectable to optimize an approach angle of elongate element(s) 130 withrespect to the patient and to an access site 132 which, in theillustrated instance, is proximate a groin of the patient. Thus sheath130 and other elongate members extending therefrom may be controllablyrotated (or angled) with respect to the patient.

Further, it is contemplated that a sterile drape is positionable onsystem 100. That is, a sterile drape (not shown) may be positionedbetween the patient and between catheter assembly 102 such thatcomponents of catheter assembly 102 (i.e., carriages 104, 106) areisolated from the patient.

FIG. 3 illustrates components of the robotic instrument driver of FIGS.1 and 2 . As discussed, robotic instrument driver 102 includes sheathcarriage 104 and leader carriage 106 positioned on rail 120. Eachcarriage 104, 106 is moveable 300 axially with respect to the other, aswell as with respect to rail 120. Elongate member 122 extends betweencarriages 104, 106 and passes through carriage 104 within sheath 130.More generally, catheter or elongate member(s) 302 extend from sheathcarriage 104 and catheter 302 may include, as an example, an outersheath or catheter, an inner catheter, and a guidewire. Sheath carriage104 is rotatable about axis 128 such that a yaw angle 304 can beimparted to catheter 302. Further, each carriage 104, 106 may have alift 306 imparted thereto as well, to cause a vertical motion and betterposition catheter 302 during operation, and to adjust to variation inpatient thickness. In addition, leader carriage 106 may also berotatable about an axis 308 such that a yaw angle 310 may be impartedthereto as well, also to reduce the propensity for catheter 302 tobuckle during operation.

The sheath carriage 104 and leader carriage 106 (or pods) may contain anarticulation mechanism for steering the pullwires of a catheter (notshown) and a manipulation mechanism for inserting, retracting androlling an elongate member. The articulation mechanism typicallyinvolves 3 or 4 pulleys in the splayer of the catheter attaching tocorresponding output shafts in the carriage, the output shaft beingdriven by motor within the pod. The steering wires running through thewall of the catheter are wrapped around the pulleys as articulation iscommanded, resulting in bending of the catheter tip. The manipulationmechanism on the sheath carriage 314 is shown as a pair of feed rollers318. The manipulation mechanism on the leader carriage is shown as agripping pad 320. These are exemplary manipulation or active drivemechanisms. It should be understood that any active drive mechanism suchas grippers, or chuck mechanism or compressible rollers may be used. Inaddition, there may be a manipulation mechanism positioned next to thepatient access site 132 to constrain and insert, retract, and/or rollsheath 130 into the patient. Active drive mechanism 312 include wheels316, in one embodiment, that cause sheath 130 to be inserted into apatient, which act in concert with sheath carriage 104 to articulatesheath 130, wherein articulation of the catheter generally refers tosteering and selectively positioning the catheter. Similarly, activedrive mechanism 314 includes wheels 318, in one embodiment, that causeleader 122 to be inserted into a patient, which act in concert withleader carriage 106 to articulate leader 122, wherein articulation ofthe catheter generally refers to steering and selectively positioningthe catheter. Similarly, active drive mechanism 320, in one embodimentmay be attached to carriage 106 to manipulate a guidewire that passesthrough the center of, and is part of, catheter 302. Active drivemechanism 312 is coupled to rail 120 and will usually not move relativeto the patient. Sheath carriage 104, and leader carriage 106 may moverelative to 312 and be controlled via workstation 112.

Thus, as shown in FIG. 3 , robotic instrument driver 102 includescarriage 104 and its corresponding active drive mechanism 314, carriage106 and its corresponding active drive mechanism 320 and active drivemechanism 312 that is directly coupled and stationary with respect torail 120 via a support 322. Support 322 may include a support structureor attachment method to support wheels 316 while allowing wheels 316 torotate and be driven, to drive sheath 130. Active drive mechanism 314 isattached to carriage 104 via its connection or attachment 324.

It is contemplated that active drive mechanism 312 is positionedproximate the patient and is configured to manipulate (insert, retractor roll) sheath 130 into or out of the patient. Carriage 104 is moveablewith respect to rail 120 and, hence, with respect to active drivemechanism 312. Active drive mechanism 314 is therefore also moveablewith respect to rail 120 and with respect to carriage 106 as well.Carriages 104 and 106 are therefore moveable independent from oneanother.

It is contemplated according to one example, that catheter assembly 102does not include carriage 106. It is also contemplated according toanother example, that catheter assembly 102 does not include carriage106 or drive mechanism 318. That is, assembly 102 may be a roboticinstrument driver 102 for driving one or more elongate members thatincludes a first carriage 312 that is positionable to or on bed 110 forinserting, retracting or roll a sheath 130 into or out of a patient.Robotic instrument driver 102 also includes a second carriage such ascarriage 104 that is positionable proximate to or on bed 110 that isconfigured to articulate sheath 130, wherein the second carriage 104 ismovable independent from the first 312. The second carriage 104 isconfigured for inserting, retracting or rolling a second elongate membersuch as an inner catheter, which is articulable from a third carriage,such as carriage 106. Further, third carriage 106 is configured inanother example to insert, retract or roll a third elongate member thatmay be, for instance, a guidewire.

FIG. 4 illustrates an exemplary anti-buckling mechanism that may beincorporated, to reduce the propensity for catheter 302 to buckle duringoperation, and in lieu of mechanisms 312, 316. Referring to FIG. 4 , ascissors-like mechanism may be placed onto catheter 302. Thescissors-like mechanism may be a collapsible passive mechanismfabricated from, for instance, plastic or metal, and of such a mass thatthe catheter extends therethrough with a scissors-action. The mechanismmay be positioned between sheath carriage 104 and the patient accesssite 132 as mechanism 400, and/or between carriages 104, 106 asmechanism 402.

Thus, in general, system 100 includes catheter insertion system 102having carriages 104, 106. Carriages 104, 106 may otherwise be referredto as lightweight pods that are separately and independentlypositionable with respect to one another. As such, system 102 avoidsusing an SUJ and the masses or pods are lightweight, reducing theoverall mass of system 100. Carriages 104, 106 are scalable in that theycan be sized according to further system catheter needs that may developover time. Carriages 104, 106 have a low profile and a low height(compared to systems having an SUJ), thus reducing the propensity tointerfere with other system equipment. Operation of carriages 104, 106may also allow for full fluoroscopic image run-off on lower extremitycases, and their operation is not sensitive to different catheterlengths. Further, additional pod/rail combinations could be includedwithin system 100. That is, one or more additional catheter controlsystems could be placed onto the bed to support further catheterprocedures (for instance, a second set of pods on a rail could beincluded on the bed and on the opposite side of the patient, and perhapsat a different axial location, than that shown in FIGS. 1 and 2 ).Further, carriages or pods 104, 106 can be easily detachable, supportinga clean and simple method for changing out system components between orduring catheterization procedures. The pods and rails shown are alignedto the access site in the femoral artery of the patient. It should beunderstood that the pods and rails can be set up toward the head of thebed for access sites in the brachial, carotid or auxiliary arteries.

The disclosed bedside system can be very lightweight and provide simplermechanics for the operating mechanisms. Also, it effectively minimizeswasted catheter length. The disclosed system is a scalable designallowing for the addition of any number of pods for various othermanipulators for other tools if desired. Thus, splayers and theiractuating motors may be mounted in pods, according to one embodiment. Asdescribed, each carrier or pod can have Z axis (up and down) and yawadjustment, whether manual or robotic. The adjustments can be used toalter the insertion angle of the catheter into the patient. In thedisclosed system, the pods may also be mounted to motorized bedsiderails providing actuation in the insert/retract directions, as well.There is also no need for setup arms, and interference with C-armmovement is reduced or eliminated. Also, pods could be easily added tothe rail making the system very scalable for other systemconfigurations. According to one option, pods are swappable such thatone pod that is designed to carry a catheter for example can be swappedwith another pod that is designed to carry a tool such as a motorizedscalpel, grasper, ablation catheter, etc. In this manner, pods can beswapped mid-procedure depending on which surgical tools are desiredduring a given procedure.

In some embodiments, the pods contain motors and encoders within the podto drive operation. A y-axis motor can include a pinion or capstan tointerface with the rail via a rack or mechanical cable, respectively. Az-axis motor can connect to a leadscrew, to drive one or multiplestages, to raise and telescope as required. Other z-axis concepts caninclude a scissor mechanism for extended vertical range. The yaw axismotor can connect to a belt and pulley or gears to rotate the pod.Rotational backlash can be minimized by a miniature harmonic drivegearbox at the motor output. The pod height is determined, in oneexample, from the table top to the top of the thinnest person’s leg,mattress included. The height, in other words, includes the volume belowthe cantilevered deck.

The rail may include a slide or track, a rack or mechanical cables, andelectrical cable harnesses for each pod. The rail can be deployable inone embodiment, meaning it is stowed at the back of the bed and slidesinto position before use. An alternative is to have a very long railreach from the end of the bed to the patient’s target. The rail can alsohave a lateral axis to provide patient lateral adjustment and to slideto each side of the table.

The y-axis (up down), z-axis (along the patient), and yaw axis are servocontrolled, in one embodiment. In this example, manual set-up is via apendant or button mounted control. This means that yaw, insertion, andheight may be adjusted relative to the target prior to driving. Pods maymove in unison vertically. Synchronous pod motion may be used to insertand retract the catheter. The pods may also yaw on a horizontaltrajectory while the catheter is inserted and retracted. If insertingand retracting on a fixed pitched angle, say 10°, height may besynchronized as well, resulting in a diving trajectory.

One challenge often experienced with robotically controlled surgicalsystems is alignment of carriage 104 with the access site of thepatient, especially as it approaches the patient. To addressmisalignment concerns, typically the operator manually maneuvers thecarriage 104 (without the sheath 130 attached) into a “fully inserted”position, whereby a nose of the instrument driver 102 is aligned and inclose proximity to the access site. The operator would then initiate a“set site” position to effectively teach the carriage 104 the “fullyinserted” position. The carriage 104 would then be retracted and thesheath 130 installed. Once installed, the carriage 104 could then beoperated to insert the sheath 130 to the installed position. As may beappreciated, the workflow for this procedure is burdensome and timeconsuming.

To address the above issues, one or more sensors 500 may be attached tothe instrument driver 102. This present disclosure contemplates that avariety of sensors 500 may be employed. Such sensors 500 include, butare not limited to a camera, a stereo camera, a range finder, aninclinometer, and a laser beam. These various sensors 500 may be usedindividually or in combination with one another.

With respect to use of a camera as sensor 500, in one exemplaryarrangement, the camera may be mounted on the instrument driver 102 inany suitable location. For embodiments that include a setup joint SUJ,the camera may alternatively be mounted to the SUJ. In one exemplaryconfiguration, the camera is mounted on the nose 502 of the instrumentdriver 102. The camera would provide a video feed to the workstation 112to allow the surgeon to visually monitor the access site as theinstrument driver 102 approaches the access site. In one exemplaryconfiguration, the video feed could be displayed as a sub-window on theworkstation 112 monitor. In this manner, the surgeon would be able tomonitor the surgical site, as well as monitor any potential binding ofan anti-buckling device, movement or loosing of a stabilizer, and anyissues at the access site.

A stereo camera could be coupled with the visual camera. The stereocamera is configured to provide distance information to various pointsin the image.

Similar to the stereo camera, a range finder may also be employed. Therange finder may be used in isolation to measure distance to the accesssite (for example to prevent collisions with the patient) or inconjunction with a camera image to infer depth of one of several pointsin the image. The range finder may utilize laser, ultrasonic, or othertechnology.

The inclinometer would directly measure a pitch angle of the instrumentdriver 102, thereby allowing adjustments to the instrument driver 102 toalign with the access site.

A laser beam may be used to project a simple pointing vector off thenose 502 of the instrument driver 102. Alternatively, the laser may beused to project a reference point onto the camera image. In oneexemplary configuration, if the laser and camera are not collocated,then the location of the reference point in the image may be used toinfer depth.

In another exemplary configuration, an automated environmental feedbackmechanism may be employed in lieu of a sensor. The automatedenvironmental feedback mechanism utilizes a beam of known speed, forexample light. To set an insertion site trajectory the beam, for examplein the form of a pulsating LED, would be emitted from the front of theinstrument driver 102 to a reflective target on a patient patch. Anarray of areas for providing a return reading would be positioned on theinstrument driver 102. Distance from the front of the patient may bedetermined by calculating the time for a signal return. Angle may alsobe geometrically determined by the point of return. These data pointsmay be then be used to electronically change the angle of the instrumentdriver 102 or carriage 104, as well as determine if the instrumentdriver 102 or carriage 104 should stop a forward or insertion movement.In one exemplary arrangement, the placement of spaced LEDs around theperimeter of the instrument driver 102 would permit use of algorithms bya computer system operatively connected to the workstation 112 and theinstrument driver 102 would permit the location of the instrument driver102 to be determined relative to other pieces of equipment in thesurgical suite.

While described in the context of using an LED as the beam, it isunderstood that any beam having a known speed and refractive qualities(i.e., the ability to reflect from the patient or a suitable patch asopposed to being absorbed or passing through) may be used. Furtherexamples include laser beams and radar.

It will be appreciated that the aforementioned method and devices may bemodified to have some components and steps removed, or may haveadditional components and steps added, all of which are deemed to bewithin the spirit of the present disclosure. Even though the presentdisclosure has been described in detail with reference to specificembodiments, it will be appreciated that the various modifications andchanges can be made to these embodiments without departing from thescope of the present disclosure as set forth in the claims. Thespecification and the drawings are to be regarded as an illustrativethought instead of merely restrictive thought.

1-20. (canceled)
 21. A robotic instrument driver, comprising: (a) afirst drive assembly, the first drive assembly being operable to: (i)articulate one or more steering wires in a first elongate member, and(ii) drive longitudinal translation of a second elongate member withrespect to the first elongate member along a first dimension, whereinthe first drive assembly is configured to be movable along a seconddimension, wherein the first drive assembly is further configured to berotatable about a first yaw axis; and (b) a second drive assembly, thesecond drive assembly being operable to: (i) articulate one or moresteering wires in the second elongate member, and (ii) drivelongitudinal translation of a third elongate member with respect to thesecond elongate member along the first dimension, wherein the seconddrive assembly is configured to be movable along the second dimension,wherein the second drive assembly is further configured to be rotatableabout a second yaw axis.
 22. The robotic instrument driver of claim 21,the first drive assembly comprising a pod.
 23. The robotic instrumentdriver of claim 21, the first drive assembly comprising a firstmanipulation mechanism configured to articulate the one or more steeringwires in the first elongate member.
 24. The robotic instrument driver ofclaim 23, the first drive assembly further comprising a first activedrive mechanism fixed relative to the first manipulation mechanism, thefirst active drive mechanism configured to insert or retract the secondelongate member with respect to the first elongate member.
 25. Therobotic instrument driver of claim 24, further comprising a secondactive drive mechanism, wherein the second active drive mechanism isconfigured to drive longitudinal translation of the first elongatemember along the first dimension.
 26. The robotic instrument driver ofclaim 21, the second drive assembly comprising a pod.
 27. The roboticinstrument driver of claim 21, the second drive assembly comprising asecond manipulation mechanism configured to articulate the one or moresteering wires in the second elongate member.
 28. The robotic instrumentdriver of claim 27, the second drive assembly further comprising asecond active drive mechanism fixed relative to the second manipulationmechanism, the second active drive mechanism configured to insert orretract the third elongate member with respect to the first elongatemember.
 29. The robotic instrument driver of claim 21, wherein the firstdrive assembly is of a type that is different from the second driveassembly.
 30. The robotic instrument driver of claim 21, wherein thefirst yaw axis is approximately orthogonal to the first dimension. 31.The robotic instrument driver of claim 21, wherein the first driveassembly and the second drive assembly are both positioned on a rail.32. The robotic instrument driver of claim 31, wherein the rail isattached to a bed.
 33. The robotic instrument driver of claim 21,wherein the first and second drive assemblies are configured to berotatable to align at least the first elongate member with an accesssite of a patient.
 34. The robotic instrument driver of claim 21,wherein the first and second drive assemblies are configured to beadjustable along the second dimension and about the respective first andsecond yaw axes to optimize an insertion angle of the first elongatemember into a patient.
 35. The robotic instrument driver of claim 21,wherein the first and second drive assemblies are configured to bemoveable along the second dimension or rotatable about the respectivefirst and second yaw axes in unison.
 36. The robotic instrument driverof claim 21, wherein the second drive assembly is movable independentlyfrom the first drive assembly.
 37. The robotic instrument driver ofclaim 21, wherein the first yaw axis is positioned along the seconddimension, wherein the second yaw axis is positioned along the seconddimension.
 38. A system, comprising: (a) a first drive assemblyconfigured to advance or retract a second elongate member relative to afirst elongate member along a first dimension, wherein the first driveassembly is configured to be movable along a second dimension, whereinthe first drive assembly is further configured to be rotatable about afirst yaw axis; and (b) a second drive assembly configured to advance orretract a third elongate member relative to the second elongate memberalong the first dimension, wherein the second drive assembly isconfigured to be movable along the second dimension, wherein the seconddrive assembly is further configured to be rotatable about a second yawaxis.
 39. The system of claim 38, wherein the first drive assembly isconfigured to be movable along the first yaw axis, wherein the seconddrive assembly is configured to be movable along the second yaw axis.40. A method, comprising: (a) articulating, via a first drive assembly,one or more steering wires in a first elongate member, the elongatemember defining a longitudinal axis; (b) articulating, via a driveassembly, one or more steering wires in a second elongate member, thesecond elongate member being disposed within the first elongate member;and (c) moving the second drive assembly independently from the firstdrive assembly, wherein the first and second drive assembly are eachconfigured to be movable along a dimension transverse to thelongitudinal axis, wherein the first and second drive assembly arefurther each configured to be rotatable independently from each other toa respective yaw angle.